Orthopaedics

Question 1

Give 5 red flags for lower back pain

Answer 1

Red flags for lower back pain
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever

Question 2

What investigations are indicated for non-specific lower back pain

Answer 2

Investigation
-lumbar spine x-ray should not be offered
MRI
-should only be offered to patients with non-specific back pain ‘only if the result is likely to change management’ and to patients where malignancy, infection, fracture, cauda equina or ankylosing spondylitis is suspected
it is the most useful imaging modality as no other imaging can see neurological / soft tissue structures

Question 3

What advice should you give people with non-specific lower back pain?what analgesia is indicated?

Answer 3

Advice to people with low back pain
try to encourage self-management
stay physically active and exercise

Analgesia
-NSAIDS are now recommended first-line for patients with back pain. This follows studies that show paracetamol monotherapy is relatively ineffective for back pain
-proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs
-NICE guidelines on neuropathic pain should be followed for patients with sciatica

Question 4

Give four treatments for non-specific lower back pain other than analgesia?

Answer 4

Other possible treatments
-exercise programme: ‘Consider a group exercise programme (biomechanical, aerobic, mindbody or a combination of approaches) within the NHS for people ‘
-manual therapy (spinal manipulation, -mobilisation or soft tissue techniques such as massage) ‘but only as part of a treatment package including exercise, with or without psychological therapy.’
-radiofrequency denervation
-epidural injections of local anaesthetic and steroid for acute and severe sciatica

Question 5

In sciatica what are the features if the L3 nerve root is compressed?

Answer 5

Sensory loss over anterior thigh
Weak hip flexion, knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test

Question 6

In sciatica what are the features if the L4 nerve root is compressed?

Answer 6

-Sensory loss anterior aspect of knee and medial malleolus
-Weak knee extension and hip adduction
-Reduced knee reflex
-Positive femoral stretch test

Question 7

In sciatica what are the features if the L5 nerve root is compressed?

Answer 7

Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test

Question 8

In sciatica what are the features if the S1 nerve root is compressed?

Answer 8

-Sensory loss posterolateral aspect of leg and lateral aspect of foot
-Weakness in plantar flexion of foot
-Reduced ankle reflex
-Positive sciatic nerve stretch test

Question 9

What is the management of sciatica?

Answer 9

Management
similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises
NICE recommend using the same drugs as for back pain without sciatica symptoms i.e. first-line is NSAIDs +/- proton pump inhibitors rather than using neuropathic analgesia (e.g. duloxetine)
if symptoms persist e.g. after 4-6 weeks) then referral for consideration of MRI is appropriate

Question 10

Describe clinical features for lower back pain due to facet joint issues?

Answer 10

-May be acute or chronic
-Pain worse in the morning and on standing
-On examination there may be pain over the facets. The pain is typically worse on extension of the back

Question 11

Describe clinical features of lower back pain due to spinal stenosis? 5

Answer 11

-Usually gradual onset
-Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
-Relieved by sitting down, leaning forwards and crouching down
-Clinical examination is often normal
-Requires MRI to confirm diagnosis

Question 12

What is lumbar spinal stenosis? how can this be differentiated from claudication?

Answer 12

Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or other similar degenerative changes.

Patients may present with a combination of back pain, neuropathic pain and symptoms mimicking claudication. One of the main features that may help to differentiate it from true claudication in the history is the positional element to the pain. Sitting is better than standing and patients may find it easier to walk uphill rather than downhill. The neurogenic claudication type history makes lumbar spinal stenosis a likely underlying diagnosis, the absence of such symptoms makes it far less likely.

Question 13

Describe the pathophysiology of lumbar spinal stenosis?

Answer 13

Degenerative disease is the commonest underlying cause. Degeneration is believed to begin in the intervertebral disk where biochemical changes such as cell death and loss of proteoglycan and water content lead to progressive disk bulging and collapse. This process leads to an increased stress transfer to the posterior facet joints, which accelerates cartilaginous degeneration, hypertrophy, and osteophyte formation; this is associated with thickening and distortion of the ligamentum flavum. The combination of the ventral disk bulging, osteophyte formation at the dorsal facet, and ligamentum flavum hyptertrophy combine to circumferentially narrow the spinal canal and the space available for the neural elements. The compression of the nerve roots of the cauda equina leads to the characteristic clinical signs and symptoms of lumbar spinal stenosis.

Question 14

What is the investigation and management of lumbar spinal stenosis?

Answer 14

MRI scanning is the best modality for demonstrating the canal narrowing. Historically a bicycle test was used as true vascular claudicants could not complete the test.

Laminectomy

Question 15

what is cauda equina syndrome? give 5 causes

Answer 15

Cauda equina syndrome (CES) is a rare but serious condition in which the lumbosacral nerve roots that extend below the spinal cord are compressed. It is important to consider CES in any patient who presents with new/worsening lower back pain. Late diagnosis may lead to permanent nerve damage resulting in long term leg weakness and urinary/bowel incontinence.

Causes
-the most common cause is a central disc prolapse
this typically occurs at L4/5 or L5/S1

other causes include:
-tumours: primary or metastatic
-infection: abscess, discitis
-trauma
-haematoma

Question 16

Give some features of cauda equina syndrome: 5

Answer 16

It is important to recognise that CES may present in a variety of ways and there is no one symptom/sign that can diagnose nor exclude CES. Possible features include
-low back pain
-bilateral sciatica
-present in around 50% of cases
-reduced sensation/pins-and-needles in the perianal area

decreased anal tone
it is good practice to check anal tone in patients with new-onset back pain
however, studies show this has poor sensitivity and specificity for CES

urinary dysfunction
e.g. incontinence, reduced awareness of bladder filling, loss of urge to void
-incontinence is a late sign that may indicate irreversible damage

Question 17

What is the investigation and management of cauda equina syndrome?

Answer 17

Investigation
urgent MRI

Management
surgical decompression

Question 18

Give clinical features of lower back pain seen in ankylosing spondylitis 3

Answer 18

Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)

Question 19

Give clinical features of lower back pain seen in peripheral arterial disease

Answer 19

-Pain on walking, relieved by rest
-Absent or weak foot pulses and other signs of limb ischaemia
-Past history may include smoking and other vascular diseases

Question 20

Femoral nerve: L2-L4
-Give the motor innervation
-Give the sensory innervation
-What is the common mechanism of injury?

Answer 20

Femoral nerve
-Knee extension, thigh flexion

-Anterior and medial aspect of the thigh and lower leg

-Hip and pelvic fractures
-Stab/gunshot wounds

Question 21

Obturator nerve L2-L4
-Give the motor innervation
-Give the sensory innervation
-What is the common mechanism of injury?

Answer 21

Thigh adduction
Medial thigh
Anterior hip dislocation

Question 22

Lateral cutaneous nerve of thigh
-Give the motor innervation
-Give the sensory innervation
-What is the common mechanism of injury?

Answer 22

None

Lateral and posterior surfaces of the thigh

Compression of the nerve near the ASIS → meralgia paraesthetica, a condition characterised by pain, tingling and numbness in the distribution of the lateral cutaneous nerve

Question 23

What is meralgia pareasthetica?

Answer 23

Meralgia paraesthetica comes from the Greek words meros for thigh and algos for pain and is often described as a syndrome of paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous nerve (LFCN). It is an entrapment mononeuropathy of the LFCN, but can also be iatrogenic after a surgical procedure, or result from a neuroma. Although uncommon, meralgia paraesthetica is not rare and is hence probably underdiagnosed.

Question 24

Give the pathophysiology of meralgia paraesthetica?

Answer 24

Anatomy
-The LFCN is primarily a sensory nerve, carrying no motor fibres.
-It most commonly originates from the L2/3 segments.
-After passing behind the psoas muscle, it runs beneath the iliac fascia as it crosses the surface of the iliac muscle and eventually exits through or under the lateral aspect of the inguinal ligament.
-As the nerve curves medially and inferiorly around the anterior superior iliac spine (ASIS), it may be subject to repetitive trauma or pressure.
-Compression of this nerve anywhere along its course can lead to the development of meralgia paraesthetica.

Question 25

Who does meralgia paraesthetica affet?

Answer 25

Epidemiology
The majority of cases occur in people aged between 30 and 40.
In some, both legs may be affected.
It is more common in men than women.
Occurs more commonly in those with diabetes than in the general population.

Question 26

Give 7 risk factors for meralgia paraesthetica?

Answer 26

Risk factors
-Obesity
-Pregnancy
-Tense ascites
-Trauma
-Iatrogenic, such as pelvic osteotomy, spinal surgeries, laparoscopic hernia repair and bariatric surgery. In some cases, may result from abduction splints used in the management of Perthe’s disease.
-Various sports have been implicated, including gymnastics, football, bodybuilding and strenuous exercise.
-Some cases are idiopathic.

Question 27

Give 5 symptoms and 3 signs of meralgia paraesthetica?

Answer 27

Patients typically present with the following symptoms in the upper lateral aspect of the thigh:
-Burning, tingling, coldness, or shooting pain
-Numbness
-Deep muscle ache
-Symptoms are usually aggravated by standing, and relieved by sitting
-They can be mild and resolve spontaneously or may severely restrict the patient for many years.

Signs:
-Symptoms may be reproduced by deep palpation just below the ASIS (pelvic compression) and also by extension of the hip.
-There is altered sensation over the upper lateral aspect of the thigh.
-There is no motor weakness.

Question 28

Give 3 investigations for meralgia paraesthetica?

Answer 28

Investigations:
-The pelvic compression test is highly sensitive, and often, meralgia paraesthetica can be diagnosed based on this test alone
-Injection of the nerve with local anaesthetic will abolish the pain. Using ultrasound is effective both for diagnosis and guiding injection therapy in meralgia paraesthetica
-Nerve conduction studies may be useful.

Question 29

Tibial nerve - L4-S3
-Give the motor innervation
-Give the sensory innervation
-What is the common mechanism of injury?

Answer 29

Tibial nerve
Foot plantarflexion and inversion
Sole of foot
Not commonly injured as deep and well protected.
Popliteral lacerations, posterior knee dislocation

Question 30

Common peroneal nerve: L4-S2
-Give the motor innervation
-Give the sensory innervation
-What is the common mechanism of injury?

Answer 30

Motor
Foot dorsiflexion and eversion
Extensor hallucis longus

Sensory
Dorsum of the foot and the lower lateral part of the leg

Injury often occurs at the neck of the fibula
Tightly applied lower limb plaster cast

Injury causes foot drop

Question 31

Superior gluteal nerve
-Give the motor innervation
-Give the sensory innervation
-What is the common mechanism of injury?

Answer 31

Motor
Hip abduction

Sensory
None

Misplaced intramuscular injection
Hip surgery
Pelvic fracture
Posterior hip dislocation

Injury results in a positive Trendelenburg sign

Question 32

Inferior gluteal nerve
-Give the motor innervation
-Give the sensory innervation
-What is the common mechanism of injury?

Answer 32

Hip extension and lateral rotation

Sensory
None

Generally injured in association
with the sciatic nerve

Injury results in difficulty rising from seated position. Can’t jump, can’t climb stairs

Question 33

Give 3 clinical features of osteoarthritis of knee

Answer 33

Patient is typically > 50 years, often overweight
Pain may be severe
Intermittent swelling, crepitus and limitation of movement may occur

Question 34

Infrapatellar bursitis - what is this assoc. with?
(Clergymans knee)

Answer 34

Associated with kneeling

Question 35

Prepatellar bursitis - what is this assoc with?

Answer 35

Associated with more upright kneeling
Housemaids knee

Question 36

Anterior cruciate ligament injury
-How may this be caused?
-What are the clinical features and what is the test used?

Answer 36

May be caused by twisting of the knee - ‘popping’ noise may have been noted
Rapid onset of knee effusion
Positive draw test

Question 37

How may the posterior cruciate ligament be injured in the knee?

Answer 37

May be caused by anterior force applied to the proximal tibia (e.g. knee hitting dashboard during car accident)

Question 38

What is found on examination of collateral ligament injury?

Answer 38

Tenderness over the affected ligament
Knee effusion may be seen

Question 39

Meniscal lesion in the knee
-How may this be caused?
-What are common features?
-What is found o.e

Answer 39

May be caused by twisting of the knee
Locking and giving-way are common feature
Tender joint line

Question 40

Give 5 clinical features of knee pain from meniscal tear

Answer 40

Typically result from twisting injuries.

Features
-pain worse on straightening the knee
-knee may ‘give way’
-displaced meniscal tears may cause knee locking
-tenderness along the joint line
-Thessaly’s test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee

Question 41

What is a bakers cyst?

Answer 41

Baker’s cysts (also known as a popliteal cyst) are not true cysts but rather a distension of the gastrocnemius-semimembranosus bursa. They may be primary or secondary:
Primary: no underlying pathology, typically seen in children
Secondary: underlying condition such as osteoarthritis, typically seen in adults

Question 42

How can bakers cysts present?

Answer 42

They present as swellings in the popliteal fossa behind the knee.

Rupture may occur resulting in similar symptoms to a deep vein thrombosis, i.e. pain, redness and swelling in the calf. However, the majority of ruptures are asymptomatic.

Question 43

What is the management of bakers cyst?

Answer 43

Baket’s cysts in children typically resolve and do not require treatment.

In adults, the underlying cause should be treated where appropriate.

Question 44

What is iliotibial band syndrome? what are the features and management?

Answer 44

Iliotibial band syndrome is a common cause of lateral knee pain in runners, occurring in around 1 in 10 people who run regularly.

Features
tenderness 2-3cm above the lateral joint line

Management
activity modification and iliotibial band stretches
if not improving then physiotherapy referral

Question 45

\What is greater trochanteric pain syndrome? what are 2 features?

Answer 45

Greater trochanteric pain syndrome is also referred to as trochanteric bursitis.

It is due to repeated movement of the fibroelastic iliotibial band and is most common in women aged 50-70 years.

Features
pain over the lateral side of hip/thigh
tenderness on palpation of the greater trochanter

Question 46

OA of the hip
-How common is this?
-Give 4 risk factors?

Answer 46

Osteoarthritis (OA) of the hip is the second most common presentation of OA after the knee. It accounts for significant morbidity and total hip replacement is now one of the most common operations performed in the developed world.

Risk factors
increasing age
female gender (twice as common)
obesity
developmental dysplasia of the hip

Question 47

Give 3 features of OA of the hip

Answer 47

Features
chronic history of groin ache following exercise and relieved by rest
red flag features suggesting an alternative cause include rest pain, night pain and morning stiffness > 2 hours
the Oxford Hip Score is widely used to assess severity

Question 48

Give the investigation and management for OA of the hip?

Answer 48

Investigations
NICE recommends that if the features are typical then a clinical diagnosis can be made
otherwise plain x-rays are the first-line investigation

Management
oral analgesia
intra-articular injections: provide short-term benefit
total hip replacement remains the definitive treatment

Question 49

Give 5 complications of total hip replacement

Answer 49

Complications of total hip replacement

perioperative
-venous thromboembolism
-intraoperative fracture
-nerve injury
-surgical site infection

leg length discrepancy

posterior dislocation
-may occur during extremes of hip flexion
typically presents acutely with a ‘clunk’, pain and inability to weight bear
-on examination there is internal rotation and shortening of the affected leg

aseptic loosening (most common reason for revision )

prosthetic joint infection

Question 50

Joint replacement - is this effective? does obesity affect the long term survival of joint replacement?

Answer 50

Joint replacement (arthroplasty) remains the most effective treatment for osteoarthritis patients who experience significant pain.

Selection criteria
around 25% of patients are now younger than 60-years-old
whilst obesity is often thought to be a barrier to joint replacement there is only a slight increase in short-term complications. There is no difference in long-term joint replacement survival

Question 51

Give 3 surgical techniques for hip replacement

Answer 51

Surgical techniques
for hips the most common type of operation is a cemented hip replacement. A metal femoral component is cemented into the femoral shaft. This is accompanied by a cemented acetabular polyethylene cup

uncemented hip replacements are becoming increasingly popular, particularly in younger more active patients. They are more expensive than conventional cemented hip replacements

hip resurfacing is also sometimes used where a metal cap is attached over the femoral head. This is often used in younger patients and has the advantage that the femoral neck is preserved which may be useful if conventional arthroplasty is needed later in life

Question 52

Give the follow up and the post-op advice given after hip replacement?

Answer 52

Post-operative recovery
patients receive both physiotherapy and a course of home-exercises
walking sticks or crutches are usually used for up to 6 weeks after hip or knee replacement surgery

Patients who have had a hip replacement operation should receive basic advice to minimise the risk of dislocation:
-avoiding flexing the hip > 90 degrees
-avoid low chairs
-do not cross your legs
-sleep on your back for the first 6 weeks

Question 53

Give 3 complications of hip replacement

Answer 53

Complications
-wound and joint infection
-thromboembolism: NICE recommend patients receive low-molecular weight heparin for 4 weeks following a hip replacement
-dislocation

Question 54

What is osteochondritis dissecans? who does this affect?

Answer 54

Osteochondritis dissecans (OCD) is a pathological process affecting the subchondral bone (most often in the knee joint) with secondary effects on the joint cartilage, including pain, oedema, free bodies and mechanical dysfunctions. It generally affects children and young adults. OCD may progress to degenerative changes if untreated.

Question 55

Give 3 clinical features of osetochondritis dissecans

Answer 55

Patients typically present with a subacute onset of:
-Knee pain and swelling, typically after exercise
-Knee catching, locking and/or giving way: more constant and severe symptoms are associated with the presence of loose bodies
-Feeling a painful ‘clunk’ when flexing or extending the knee - indicating the involvement of the lateral femoral condyle

Question 56

Give 3 signs of osteochondritis dissecans?

Answer 56

Signs:
-Joint effusion
-Tenderness on palpation of the articular cartilage of the medial femoral condyle, when the knee is flexed
-Wilson’s sign for detecting medial condyle lesion - with the knee at 90° flexion and tibia internally rotated, the gradual extension of the joint leads to pain at about 30°, external rotation of the tibia at this point relieves the pain

Question 57

What are the investigations and management of osteochondritis dissecans?

Answer 57

Investigations:
X-ray (anteroposterior, lateral and tunnel views) - may show the subchondral crescent sign or loose bodies
MRI - used to evaluate cartilage, visualise loose bodies, stage and assess the stability of the lesion

Management
Early diagnosis is important
Clinical signs may be subtle in the early stages hence there should be a low threshold for imaging and/or orthopaedic opinion.

Question 58

Who should be assessed for osteoporosis? what are 8 risk factors?

Answer 58

They advise that all women aged >= 65 years and all men aged >= 75 years should be assessed. Younger patients should be assessed in the presence of risk factors, such as:
-previous fragility fracture
-current use or frequent recent use of oral or systemic glucocorticoid
-history of falls
-family history of hip fracture
-other causes of secondary osteoporosis
low body mass index (BMI) (less than 18.5 kg/m²)
-smoking
-alcohol intake of more than 14 units per week for women and more than 14 units per week for men.

Question 59

How should patients be assessed for osteoporosis?

Answer 59

NICE recommend using a clinical prediction tool such as FRAX or QFracture to assess a patients 10 year risk of developing a fracture. This is analogous to the cardiovascular risk tools such as QRISK.

Question 60

FRAX
-What is this?
-Who is this valid for?
-What is included in assessment?
-When would a DEXA be arranged?

Answer 60

FRAX
-estimates the 10-year risk of fragility fracture
-valid for patients aged 40-90 years
-based on international data so use not limited to UK patients
-assesses the following factors: age, sex, weight, height, previous fracture, parental fracture, current smoking, glucocorticoids, rheumatoid arthritis, secondary osteoporosis, alcohol intake
-bone mineral density (BMD) is optional, but clearly improves the accuracy of the results. NICE recommend arranging a DEXA scan if FRAX (without BMD) shows an intermediate result

Question 61

How do you interpret FRAX score if done without DEXA? How do you intepret if DEXA has been done?

Answer 61

If the FRAX assessment was done without a bone mineral density (BMD) measurement the results (10-year risk of a fragility fracture) will be given and categorised automatically into one of the following:
low risk: reassure and give lifestyle advice
intermediate risk: offer BMD test
high risk: offer bone protection treatment

Therefore, with intermediate risk results FRAX will recommend that you arrange a BMD test to enable you to more accurately determine whether the patient needs treatment

If the FRAX assessment was done witha bone mineral density (BMD) measurement the results (10-year risk of a fragility fracture) will be given and categorised automatically into one of the following:
reassure
consider treatment
strongly recommend treatment

Question 62

QFracture
-What is this?
-Who can this be used in?
-How is this different from FRAX?

Answer 62

QFracture
estimates the 10-year risk of fragility fracture
developed in 2009 based on UK primary care dataset
can be used for patients aged 30-99 years (this is stated on the QFracture website, but other sources give a figure of 30-85 years)
includes a larger group of risk factors e.g. cardiovascular disease, history of falls, chronic liver disease, rheumatoid arthritis, type 2 diabetes and tricyclic antidepressants

Question 63

How is QFracture interpreted?

Answer 63

If you use QFracture instead patients are not automatically categorised into low, intermediate or high risk. Instead the ‘raw data’ relating to the 10-year risk of any sustaining an osteoporotic fracture. This data then needs to be interpreted alongside either local or national guidelines, taking into account certain factors such as the patient’s age.

Question 64

Who gets a DEXA scan rather than using a clinical prediction tool for osteoporosis?

Answer 64

There are some situations where NICE recommend arranging BMD assessment (i.e. a DEXA scan) rather than using one of the clinical prediction tools:
-before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer).
-in people aged under 40 years who have a major risk factor, such as history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer).

Question 65

When should a patient be reassessed with FRAX / QFracture

Answer 65

NICE recommend that we recalculate a patient’s risk (i.e. repeat the FRAX/QFracture):

if the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of 2 years, or
when there has been a change in the person’s risk factors

Question 66

What is an acetabular labral tear?

Answer 66

Labral tears may occur following trauma (most commonly in younger adults) or as a result of degenerative change (typically in older adults).

Features
hip/groin pain
snapping sensation around hip
there may occasionally be the sensation of locking

Question 67

Achilles tendon disorders:
-Are these common?
-What are 2 risk factors?

Answer 67

Achilles tendon disorders are the most common cause of posterior heel pain. Possible presentations include tendinopathy (tendinitis), partial tear and complete rupture of the Achilles tendon.

Risk factors
quinolone use (e.g. ciprofloxacin) is associated with tendon disorders
hypercholesterolaemia (predisposes to tendon xanthomata)

Question 68

Achilles tendinopathy:
-Give 2 features
-Give 3 management options

Answer 68

Features
gradual onset of posterior heel pain that is worse following activity
morning pain and stiffness are common

The management is typically supportive
simple analgesia
reduction in precipitating activities
calf muscle eccentric exercises: this may be self-directed or under the guidance of physiotherapy

Question 69

When should you suspect achilles tendon rupture? What is the examination?

Answer 69

Achilles tendon rupture should be suspected if the person describes the following whilst playing a sport or running; an audible ‘pop’ in the ankle, sudden onset significant pain in the calf or ankle or the inability to walk or continue the sport.

An examination should be conducted using Simmond’s triad, to help exclude Achilles tendon rupture. This can be performed by asking the patient to lie prone with their feet over the edge of the bed. The examiner should look for an abnormal angle of declination; Achilles tendon rupture may lead to greater dorsiflexion of the injured foot compared to the uninjured limb. They should also feel for a gap in the tendon and gently squeeze the calf muscles if there is an acute rupture of the Achilles tendon the injured foot will stay in the neutral position when the calf is squeezed.

Question 70

What is the investigation and management of acute achilles tendon rupture?

Answer 70

Ultrasound is the initial imaging modality of choice for suspected Achilles tendon rupture

An acute referral should be made to an orthopaedic specialist following a suspected rupture.

Question 71

Give 3 ottowa rules for ankle xrays?

Answer 71

The Ottawa Rules for ankle x-rays have a sensitivity approaching 100%

An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
-bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
-bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
-inability to walk four weight-bearing steps immediately after the injury and in the emergency department

Question 72

What is a charcot joint? Give 2 clinical features

Answer 72

A Charcot joint is also commonly referred to as a neuropathic joint. It describes a joint which has become badly disrupted and damaged secondary to a loss of sensation. In years gone by they were most commonly caused by neuropathy secondary to syphilis (tabes dorsalis) but are now most commonly seen in diabetics.

Features
Charcot joints are typically a lot less painful than would be expected given the degree of joint disruption due to the sensory neuropathy. However, 75% of patients report some degree of pain
the joint is typically swollen, red and warm

Question 73

What is talipes equinovarus? is this more common in boys or girls? give 5 association

Answer 73

Talipes equinovarus, or club foot, describes an inverted (inward turning) and plantar flexed foot. It is usually diagnosed on the newborn exam.

Talipes equinovarus is twice as common in males than females and has an incidence of 1 per 1,000 births. Around 50% of cases are bilateral.

Most commonly idiopathic. Associations include:
spina bifida
cerebral palsy
Edward’s syndrome (trisomy 18)
oligohydramnios
arthrogryposis

Question 74

What is the diagnosis and management of talipes equinovarus?

Answer 74

The diagnosis is clinical (the deformity is not passively correctable) and imaging is not normally needed.

Management*
-in recent years there has been a move away from surgical intervention to more conservative methods such as the Ponseti method
-the Ponseti method consists of manipulation and progressive casting which starts soon after birth. The deformity is usually corrected after 6-10 weeks. An Achilles tenotomy is required in around 85% of cases but this can usually be done under local anaesthetic
-night-time braces should be applied until the child is aged 4 years. The relapse rate is 15%

Question 75

What is mortons neuroma? give 4 features

Answer 75

Morton’s neuroma is a benign neuroma affecting the intermetatarsal plantar nerve, most commonly in the third inter-metatarsophalangeal space. The female to male ratio is around 4:1.

Features
forefoot pain, most commonly in the third inter-metatarsophalangeal space
worse on walking. May be described as a shooting or burning pain. Patients may feel they have a pebble in their shoe
Mulder’s click: one hand tries to hold the neuroma between the finger and thumb. The other hand squeezes the metatarsals together. A click may be heard as the neuroma moves between the metatarsal heads
there may be loss of sensation distally in the toes

Question 76

what is the diagnosis and management of mortons neuroma?

Answer 76

Diagnosis is usually clinical although ultrasound may be helpful in confirming the diagnosis.

Management
avoid high-heels
metatarsal pad
CKS recommends referral if symptoms persist for > 3 months despite footwear modifications and the use of metatarsal pads
orthotists may give the patient a metatarsal dome orthotic
other secondary care options include corticosteroid injection and neurectomy of the involved interdigital nerve and neuroma

Question 77

Musculocutaneous nerve: C5-C7
-What is the motor innervation?
-What is the sensory innervation?
-What are the common mechanisms of injury?

Answer 77

Motor
Elbow flexion (supplies biceps brachii) and supination

Sensory
Lateral part of the forearm

Common mechanisms of injury
Isolated injury rare - usually injured as part of brachial plexus injury

Question 78

Axillary nerve: C5,C6
-What is the motor innervation?
-What is the sensory innervation?
-What are the common mechanisms of injury?

Answer 78

Motor
Shoulder abduction (deltoid muscle)

Sensory
Inferior region of the deltoid muscle

Common mechanisms
Humeral neck fracture/dislocation
Results in flattened deltoid

Question 79

Radial nerve: C5-C8
-What is the motor innervation?
-What is the sensory innervation?
-What are the common mechanisms of injury?

Answer 79

Motor
Extension (forearm, wrist, fingers, thumb)

Sensory
Small area between the dorsal aspect of the 1st and 2nd metacarpals

Mechanism
Humeral midshaft fracture

Palsy results in wrist drop

Question 80

median nerve C6, C8, T1
-What is the motor innervation?
-What is the sensory innervation?
-What are the common mechanisms of injury?

Answer 80

Motor
LOAF muscles
-Lateral two lumbricals
-Opponens pollis
-Abductor pollis brevis
-Flexor pollis brevis

Features depend on the site of the lesion:
wrist: paralysis of thenar muscles, opponens pollicis
elbow: loss of pronation of forearm and weak wrist flexion

Sensory
Palmar aspect of lateral 3½ fingers

Mechanism
Wrist lesion → carpal tunnel syndrome

Question 81

Ulnar nerve C8, T1
-What is the motor innervation?
-What is the sensory innervation?
-What are the common mechanisms of injury?

Answer 81

Motor
Intrinsic hand muscles except LOAF

Sensory
Wrist flexion Medial 1½ fingers

Mechanism
Medial epicondyle fracture

Damage may result in a ‘claw hand’

Question 82

Long thoracic nerve - C5-C7
-What does this innervate
-What are common mechanisms of injury?
-What can damage result in?

Answer 82

Serratus anterior

Often during sport e.g. following a blow to the ribs. Also possible complication of mastectomy

Damage results in a winged scapula

Question 83

What is erb-duchenne palsy?
-What is this due to?
-What does this look like?

Answer 83

Erb-Duchenne palsy (‘waiter’s tip’)
due to damage of the upper trunk of the brachial plexus (C5,C6)
may be secondary to shoulder dystocia during birth
the arm hangs by the side and is internally rotated, elbow extended

Question 84

What is Klumpke injury?
-What may this be caused by?
-What is this assoc with?

Answer 84

Klumpke injury
due to damage of the lower trunk of the brachial plexus (C8, T1)
as above, may be secondary to shoulder dystocia during birth. Also may be caused by a sudden upward jerk of the hand
associated with Horner’s syndrome
Ape and claw hand

Question 85

What is adhesive capsulitis? what is an association? Give 5 clinical features?

Answer 85

Adhesive capsulitis (frozen shoulder) is a common cause of shoulder pain. It is most common in middle-aged females. The aetiology of frozen shoulder is not fully understood.

Associations
diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder

Features typically develop over days
external rotation is affected more than internal rotation or abduction
both active and passive movement is affected
patients typically have a painful freezing phase, an adhesive phase and a recovery phase
bilateral in up to 20% of patients
the episode typically lasts between 6 months and 2 years

Question 86

What is the investigation and management of adhesive capsulitis?

Answer 86

The diagnosis is usually clinical although imaging may be required for atypical or persistent symptoms.

Management
no single intervention has been shown to improve outcome in the long-term
treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids

Question 87

Give 3 features of lateral epicondylitis? tennis elbow

Answer 87

Features
-pain and tenderness localised to the lateral epicondyle
-pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
-episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks

Question 88

Give 3 features of medial epicondylitis?

Answer 88

Features
pain and tenderness localised to the medial epicondyle
pain is aggravated by wrist flexion and pronation
symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement

Question 89

What is radial tunnel syndrome? what are 3 features?

Answer 89

Most commonly due to compression of the posterior interosseous branch of the radial nerve. It is thought to be a result of overuse.

Features
-symptoms are similar to lateral epicondylitis making it difficult to diagnose
-however, the pain tends to be around 4-5 cm distal to the lateral epicondyle
-symptoms may be worsened by extending the elbow and pronating the forearm

Question 90

What is cubital tunnel syndrome? give 3 features?

Answer 90

Due to the compression of the ulnar nerve.

Features
initially intermittent tingling in the 4th and 5th finger
may be worse when the elbow is resting on a firm surface or flexed for extended periods
later numbness in the 4th and 5th finger with associated weakness

Question 91

Give 4 features of cubital tunnel syndrome? what is the investigations and management?

Answer 91

Clincial features
-Tingling and numbness of the 4th and 5th finger which starts off intermittent and then becomes constant.
-Over time patients may also develop weakness and muscle wasting
-Pain worse on leaning on the affected elbow
-Often a history of osteoarthritis or prior trauma to the area.

Investigations
the diagnosis is usually clinical
however, in selected cases nerve conduction studies may be used

Management
Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery in resistant cases

Question 92

What is olecranon bursitis?

Answer 92

Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.

Question 93

What is carpal tunnel syndrome? give 3 symptoms

Answer 93

Carpal tunnel syndrome is caused by compression of median nerve in the carpal tunnel.

History
pain/pins and needles in thumb, index, middle finger
unusually the symptoms may ‘ascend’ proximally
patient shakes his hand to obtain relief, classically at night

Question 94

What 4 features are seen oe in carpal tunnel? give 5 causes

Answer 94

Examination
-weakness of thumb abduction (abductor pollicis brevis)
-wasting of thenar eminence (NOT hypothenar)
-Tinel’s sign: tapping causes paraesthesia
-Phalen’s sign: flexion of wrist causes symptoms

Causes
-idiopathic
-pregnancy
-oedema e.g. heart failure
-lunate fracture
-rheumatoid arthritis

Question 95

What is the investigation and management of carpal tunnel syndrome?

Answer 95

Electrophysiology
motor + sensory: prolongation of the action potential

Treatment
NICE Clinical Knowledge Summaries currently recommends a 6-week trial of conservative treatments if the symptoms are mild-moderate
corticosteroid injection
wrist splints at night: particularly useful if transient factors present e.g. pregnancy
if there are severe symptoms or symptoms persist with conservative management:
surgical decompression (flexor retinaculum division)

Question 96

What is de quervains tenosinuvitis? give 4 features

Answer 96

De Quervain’s tenosynovitis is a common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged 30 - 50 years old.

Features
-pain on the radial side of the wrist
-tenderness over the radial styloid process
-abduction of the thumb against resistance is painful
-Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and -longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus

Question 97

what is the management of de quervains tenosinivitis?

Answer 97

Management
-analgesia
-steroid injection
-immobilisation with a thumb splint (spica) may be effective
-surgical treatment is sometimes required

Question 98

How common is dupuytrens contracture? give 5 specific causes

Answer 98

Dupuytren’s contracture has a prevalence of about 5%. It is more common in older male patients and around 60-70% have a positive family history

Specific causes include:
manual labour
phenytoin treatment
alcoholic liver disease
diabetes mellitus
trauma to the hand

Association with liver cirrhosis and alcoholism. However, many cases are idiopathic.

Question 99

What is the management of dupuytrens contracture?

Answer 99

Features
the ring finger and little finger are the fingers most commonly affected

Management
consider surgical treatment of Dupuytren’s contracture when the metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table

Question 100

What is a ganglion? what are the clinical features? what is the management?

Answer 100

A ganglion presents as a ‘cyst’ arising from a joint or tendon sheath. They are most commonly seen around the dorsal aspect of the wrist and are 3 times more common in women.

Features
a firm and well-circumscribed mass that transilluminates

Management
ganglions often disappear spontaneously after several months
surgical excision is indicated for cysts associated with severe symptoms or neurovascular manifestations

Question 101

What are oslers nodes?

Answer 101

Osler’s nodes are painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes.

Question 102

What are bouchards nodes?

Answer 102

Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage.

Question 103

What are heberdens nodes?

Answer 103

Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways.

Question 104

what is intersection syndrome? give 3 features

Answer 104

Intersection syndrome is a tenosynovitis caused by inflammation where the abductor pollicis longus and extensor pollicis brevis muscles cross over (or intersect) the tendons of the extensor carpi radialis longus and the extensor carpi radialis brevis.

Features
intersection syndrome is commonly misdiagnosed as de Quervain’s tenosynovitis
pain in the distal dorsoradial forearm, around 5-10 cm proximal of the wrist joint
swelling and erythema may be seen

Question 105

Intersection syndrome- who is this most commonly seen in? give 4 management options

Answer 105

Intersection syndrome is commonly seen in skiers, tennis players, weight lifters and canoeists.

Management
NSAIDs
steroid injection
physiotherapy
surgical treatment is rarely required

Question 106

What is a myxoid cyst?

Answer 106

Myxoid cysts (also known as mucous cysts) are benign ganglion cysts usually found on the distal, dorsal aspect of the finger. There is usually osteoarthritis in the surrounding joint. They are more common in middle-aged women.

Question 107

OA of the hand - who is this most common in?

Answer 107

Osteoarthritis (OA) of the hands is sometimes referred to as nodal arthritis. It results from the loss of cartilage at synovial joints and is often accompanied by the degeneration of underlying bone.

Epidemiology
There may be a positive family history
More commonly affects women (M:F 1:3)
Rare to present before 55 years of age
Radiologic signs are more common than symptoms
The presence of hand OA increases the risk of future hip and knee OA (higher for hip OA than for knee OA)

Question 108

What are 5 risk factors for OA in hand?

Answer 108

Risk factors:
Previous trauma of a joint increases the risk of having OA in that joint
Obesity
Hypermobility of a joint increases the risk of OA in that joint
Occupation e.g. cotton workers and farmers are more susceptible to hand OA
Osteoporosis reduces the risk of OA

Question 109

Give 6 features of OA of hand

Answer 109

Features:
-Usually bilateral: Usually one joint at a time is affected over a period of several years. The carpometacarpal joints (CMCs), distal interphalangeal joints (DIPJs) are affected more than the proximal interphalangeal joints (PIPJs).

-Episodic joint pain: An intermittent ache. Provoked by movement and relieved by resting the joint.

Stiffness
-worse after long periods of inactivity e.g. waking up in the morning
-stiffness lasts only a few minutes compared to the morning joint stiffness seen in rheumatoid arthritis.

Painless nodes (bony swellings)
-Heberden’s nodes at the DIP joints
-Bouchard’s Nodes at the PIP joints
these nodes are the result of osteophyte formation.

Squaring of the thumbs: Deformity of the carpometacarpal joint of the thumb resulting in fixed adduction of the thumb.

Functionally patients do not usually have any problems. If there is severe involvement of the DIPJs, there may be reduced grip strength which can result in disuse atrophy.

Question 110

Give the investigation for OA of hand

Answer 110

Investigations:
X-ray: radiologically there are osteophytes and joint space narrowing. Often signs may be visible on X-ray, before symptoms develop

Question 111

What is trigger finger and give 3 associations

Answer 111

Trigger finger is a common condition associated with abnormal flexion of the digits. It is thought to be caused by a disparity between the size of the tendon and pulleys through which they pass. In simple terms the tendon becomes ‘stuck’ and cannot pass smoothly through the pulley.

Associations* (idiopathic in the majority)
more common in women than men
rheumatoid arthritis
diabetes mellitus

Question 112

Give 3 features and 2 management options for trigger finger

Answer 112

Features
more common in the thumb, middle, or ring finger
initially stiffness and snapping (‘trigger’) when extending a flexed digit
a nodule may be felt at the base of the affected finger

Management
steroid injection is successful in the majority of patients. A finger splint may be applied afterwards
surgery should be reserved for patients who have not responded to steroid injections

Question 113

what are sarcomas and how can these be categorised?

Answer 113

Sarcomas are a diverse group of malignant tumours originating from mesenchymal tissue. They are relatively rare, accounting for approximately 1% of adult and 15% of paediatric cancers. Sarcomas can be classified into two main categories: bone sarcomas and soft tissue sarcomas.

Question 114

Give 3 bone sarcomas and 6 soft tissue sarcomas

Answer 114

Sarcomas can be classified based on their tissue of origin:

Bone Sarcomas
-Osteosarcoma
-Chondrosarcoma
-Ewing’s sarcoma

Soft Tissue Sarcomas
-Liposarcoma
-Rhabdomyosarcoma (striated muscle origin)
-Synovial sarcoma
-Fibrosarcoma
-Angiosarcoma
-Leiomyosarcoma (smooth muscle origin))

Question 115

give 5 common clinical manifestations of sarcoma?

Answer 115

Sarcomas can present with a wide range of symptoms, depending on the location and size of the tumour. Common clinical manifestations include:

Pain: Often a presenting symptom in bone sarcomas and occasionally in soft tissue sarcomas.

Swelling or a palpable mass: More common in soft tissue sarcomas.

Impaired function: Depending on the location, sarcomas may cause limitations in motion, difficulty breathing, or other functional impairments.

Pathologic fractures: Bone sarcomas can weaken the bone, leading to fractures.

Systemic symptoms: Fatigue, weight loss, and fever may be present, particularly in advanced cases.

Question 116

What is the investigation for sarcoma

Answer 116

Investigations
Imaging: X-rays, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) scans help to identify and localize the tumour, assess its size, and evaluate metastatic spread.
Biopsy: A tissue sample is obtained, either through a fine needle aspiration (FNA), core needle biopsy, or incisional biopsy, for histopathological analysis to confirm the diagnosis and determine the tumour grade.

Question 117

give 5 management options of sarcomas

Answer 117

Management

Surgery: The primary treatment for most sarcomas, aiming for complete resection with negative margins to reduce the risk of local recurrence. In some cases, limb-sparing surgery can be performed to preserve function, while amputation may be necessary for more advanced or aggressive tumours.

Radiation therapy: Often used in conjunction with surgery, either preoperatively (neoadjuvant) to shrink the tumour or postoperatively (adjuvant) to minimize the risk of local recurrence. In some cases, intraoperative radiation therapy (IORT) may be employed for better tumour control.

Chemotherapy: Systemic therapy is typically used in the neoadjuvant or adjuvant setting to reduce the risk of metastatic spread, especially for high-grade tumours or those with a high risk of recurrence. In some cases, chemotherapy is used for palliative purposes in advanced or metastatic disease.

Targeted therapy: For specific sarcoma subtypes, such as GIST, targeted therapy with tyrosine kinase inhibitors (e.g., imatinib) has shown significant efficacy.

Immunotherapy: Immune checkpoint inhibitors and other immunotherapies are being investigated for potential use in the treatment of sarcomas, particularly in advanced or metastatic cases.